DQA Quarterly Information Update OCTOBER 2014

Transcription

1 Wisconsin Department of Health Services Division of Quality Assurance Otis Woods, Administrator DQA Quarterly Information Update OCTOBER 2014 Telephone: (608) TTY: (608) FAX: (608) NEW THIS ISSUE CMS Guidance on CPR Requirements DQA Post Survey Questionnaire... 2 FOCUS SIGN UP! UW Oshkosh Caregiver Project Workshops.. 4 SRO Quarterly Communication Meeting. 5 Handheld Devices Guidance Reminder.. 6 OASIS-C1/ICD-9 for Home Health Agencies.. 7 REGULAR FEATURES Changes in DQA Staff 7 DQA Numbered Memos... 8 CMS Survey & Certification Letters DQA QUARTERLY INFORMATION UPDATE CONTACT Gina Bertolini Records and Forms Management Specialist Division of Quality Assurance P.O. Box 2969 Madison, WI Gina.Bertolini@dhs.wisconsin.gov (608) SUBSCRIPTION SERVICES Wheat ready for harvest (illustration from the Tacuinum Sanitatas, a medieval health book; Biblioteca Casanatense, Rome), late 14 th c; in the Lombard artistic tradition, school of Giovanni de Grassi NEW THIS ISSUE CMS Guidance on CPR Requirements Bureau of Nursing Home Resident Care CMS has provided additional guidance on the requirements for nursing home staff and cardio pulmonary resuscitation (CPR) requirements. Per CMS, at least one staff person who is certified in CPR must accompany nursing home residents whenever they leave the facility on an outing. This person must be a facility employee and cannot be a volunteer. (continued)

2 DQA Quarterly Information Update OCTOBER 2014 Page 2 According to the Centers for Medicare and Medicaid Services (CMS) memo 14-01, dated October 18, 2013, Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident s advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR-certified staff must be available at all times. CMS also noted that the provisions of the Social Security Act and the regulations stipulate that service provided or arranged by the facility must meet professional standards of quality and be provided by qualified persons in accordance with each resident s written plan of care. Because individuals can override their do-not-resuscitate orders at any time, a staff person who is CPRcertified should accompany residents on an outing even if all the residents on the outing have do-notresuscitate orders. Please direct any questions you have concerning this to your BNHRC Regional Field Operations Director. DQA Post Survey Questionnaire The Post Survey Questionnaire (DQA form F-62579) is available to providers in convenient formats --- paper, on-line select survey, and electronic (Word fillable and PDF). Use any version of the Post Survey Questionnaire to provide DQA with valuable feedback. Comments and responses to the questions will be used to evaluate and review the survey system and to improve the quality of the survey process. Data provided in your response to the questionnaire will not influence state licensure or certification status. The identity of the provider/supplier and survey staff will remain anonymous throughout the analysis and interpretation of the data. Although every effort will be made to maintain anonymity, please be aware that the DQA Post Survey Questionnaire responses are subject to disclosure under the Wisconsin Open Records Law. We ask that each provider complete only one questionnaire per survey event --- on-line, paper, Word fillable, or PDF. (Complete and submit on- On-line: line.) Paper: Paper copies of form are available from surveyors; complete and mail to address below. Word fillable: (Complete electronically, print, and mail to address below.) PDF: (Print, complete, and mail.) Mailing Address: DHS / Division of Quality Assurance PO Box 2969 Madison, WI

3 DQA Quarterly Information Update OCTOBER 2014 Page 3 FOCUS 2014 Bureau of Education Services and Technology FOCUS 2014 Special Session: The Art and Science of End of Life Care Wednesday, November 19, 2014 Cost: $90.00 FOCUS 2014 Conference: Teach, Learn, Collaborate Thursday, November 20, 2014 Cost: $ The Wisconsin Department of Health Services (DHS), Division of Quality Assurance (DQA), is pleased to announce the 13th annual conference for health care providers and DQA staff on November 19 and 20, 2014, at the Kalahari Convention Center in Wisconsin Dells. The Focus 2014 Conference is being developed in collaboration with health care provider and provider association representatives. At FOCUS 2014, attendees will have access to leading experts in the health care field, the chance to network with others, and an opportunity to visit the numerous exhibit booths. This year, the Special Session will focus on End of Life Care. This topic is receiving special attention in order to increase both awareness of the issue and efforts to address the best care options. This special session is intended for staff from assisted living facilities, DQA, facilities serving individuals with intellectual disabilities, home health agencies, hospice providers, hospitals, nursing homes, and pharmacists. The Special Session keynote speaker will feature Dr. Ira Byock; the title of his keynote is Providing The Best Care Possible through End of Life. Dr. Byock will talk about how a transformation is needed in the way our society and culture, not merely our health care system, cares for seriously ill people and supports family caregivers. He will also address how effective advocacy by patients and families is needed to avoid common mistakes, avert suffering, and prevent regrets. Several breakout sessions will be offered covering topics which include the end of life medications and symptom management, end stage dementia care, hospice and palliative care information, and human development. The theme of the FOCUS 2014 Conference is Teach, Learn, Collaborate. The goal of the conference is to provide attendees with as many tools as possible to improve the health and safety of Wisconsin residents living in health care facilities. This conference is intended for staff from assisted living facilities, DQA, facilities serving individuals with intellectual disabilities, and nursing homes. This year s FOCUS 2014 keynote address will feature Dr. Allen Power; the title of his keynote is Dementia Beyond Disease: Enhancing Well-Being. Dr. Power will talk about how to overturn the prevailing diseasebased care practices by emphasizing well-being and the many ways it can be enhanced in people with dementia. He will also address dementia care practices, presenting approaches that promise a new and hopeful vision for achieving the best possible outcomes for every person touched by this debilitating disease. The agenda for this innovative conference includes breakout sessions on bullying in the health care workplace, decreasing antipsychotic use for individuals with dementia, financial fraud and abuse, intimacy and sexuality in dementia care, support for older persons with intellectual disabilities, and transitions of care. These are just a few of the topics that will be covered.

4 DQA Quarterly Information Update OCTOBER 2014 Page 4 Register now at: For Registration Questions: Contact UW-Stevens Point Continuing Education at uwspce-conf@uwsp.edu or For Content or Breakout Session Questions: Contact Leann Graffin at leann.graffin@dhs.wisconsin.gov or SIGN UP! UW Oshkosh Caregiver Project Workshops The University of Wisconsin Oshkosh Center for Career Development (CCDET) and the Division of Quality Assurance (DQA) are pleased to announce upcoming workshops in October and November 2014 in the Green Bay and Milwaukee areas. These workshops are partially subsidized by DQA. Continuing Education for Caregivers: Training for Trainers This full-day workshop, at a cost of $150 per participant (including lunch), combines the former Topical Training for Trainers and the Experiential Video Training for Trainers. Participants will receive: An overview of all training materials Copies of selected Facilitator Guides and handouts Suggestions for matching training modules with specific continuing education requirements Training tips and an opportunity to participate in several training activities This workshop introduces participants to over 30 hours of Caregiver Project training materials designed to prevent abuse and neglect, increase quality of care, and meet continuing education requirements for caregivers in settings regulated by DQA. Upon completion of the workshop, participants will be able to train direct caregivers and other staff in their own facilities. NOTE for CBRF Approved Instructors: This class is approved by DQA for three hours of required adult learning continuing education. In addition, instructors of Medication Administration and Fire Safety courses are eligible for additional credits. For more information, see website at: Investigating and Reporting Allegations of Misconduct This half-day workshop, at a cost of $95 per participant, will help participants identify the key components of conducting internal investigations into allegations of abuse, neglect, and misappropriation. IMPORTANT NOTE: Separate versions of this training are available for non-nursing home providers and nursing home providers. Please see workshop schedule for details. (continued)

5 DQA Quarterly Information Update OCTOBER 2014 Page 5 Participants will develop an investigation protocol while learning about: Conducting an investigation Interviewing skills Caregiver misconduct definitions Reporting requirements Both workshops will be presented on consecutive days in the following cities this fall: October 21-22, Green Bay November 5-6, Brookfield (Milwaukee area) You may attend one or both days in each city --- material is different each day. Registration is open to multiple individuals per facility. Learn more about the training or sign up today at: SRO Quarterly Communication Meeting Bureau of Nursing Home Resident Care (Southern Regional Office) Thanks are extended to all who came to the January, April, and July Quarterly Communication Meetings hosted by the Southern Regional Office, Bureau of Nursing Home Resident Care. PLEASE NOTE THAT THIS IS A CHANGE OF DATE! The next meeting is scheduled for: Wednesday, October 29, :00-3:00 PM The meeting will be held at: Iowa County Health and Human Services Building Community Room 303 W. Chapel St. Dodgeville, WI There is no cost to attend these meetings and everyone is encouraged to participate. Pat Virnig, SRO Regional Field Operations Director, and Ann Angell, SRO Regional Field Operations Supervisor, will meet with facility staff from throughout the Southern Region in an informal communication format. If there are questions or specific topics you would like addressed at an upcoming meeting, contact Pat or Ann so that they can ensure the agenda reflects the needs of those attending. Pat Virnig: Patricia.Virnig@dhs.wisconsin.gov Ann Angell: Ann.Angell@dhs.wisconsin.gov

6 DQA Quarterly Information Update OCTOBER 2014 Page 6 Handheld Devices Guidance Reminder Office of Caregiver Quality The Office of Caregiver Quality (OCQ) has primary responsibility for receiving, screening, and investigating allegations of caregiver misconduct and maintaining the Wisconsin Caregiver Misconduct Registry. Since 2009 the Office of Caregiver Quality has seen an increase in the number of Caregiver Misconduct issues related to the increased use of wireless handheld devices such as cameras on cell phones, PDAs, and laptops. These devices provide instant access to the internet and allow information to be transmitted electronically or maintained in another form or medium. OCQ continues to receive reports of misconduct involving handheld devices. There are many popular online social media outlets such as Facebook, Twitter, Instagram, and YouTube. One new outlet that is growing in popularity is Snapchat.com which is a photo messaging application that allows you to Snap a photo or a video, add a caption, and send to a friend. Personal photographs or videos taken of residents/patients that identify or allow for the identification of residents/patients generally constitute protected health information. In addition, misuse of handheld devices including distribution of photos and videos may violate resident rights, HIPAA violations, and may constitute caregiver misconduct. Entities are strongly encouraged to regularly review and update policies and handbooks regarding the use of handheld devices by staff to assure that they are reflective of current (and future) technologies in order to assure resident/patient protection and privacy. Facility policies should prohibit staff from discussing resident/patient information on blogs, social media, or other internet platforms and from taking photographs of residents/patients on personal handheld devices. In addition, health or residential care facilities should provide staff with ongoing training on resident rights, privacy, and security. If you have questions regarding caregiver misconduct issues, contact the Office of Caregiver Quality at DHSCaregiverIntake@wisconsin.gov or (608) OASIS-C1/ICD-9 for Home Health Agencies Bureau of Educational Services and Technology OASIS-C1/ICD-9 will be the next update for the current OASIS-C patient assessment dataset utilized by federally-certified home health agencies (HHAs) as a portion of their comprehensive patient assessments. The dataset is used on skilled, adult, non-maternity Medicare and Medicaid patients. CMS released the new C1/ICD-9 draft dataset on June 17, This new C1 dataset becomes effective on January 1, 2015, while still utilizing current ICD-9 coding for all the C1 questions that involve diagnosis coding. The draft C1/ICD-9 dataset is expected to be approved by the Office of Management and Budget (OMB) prior to implementation. CMS hosted a live OASIS-C1/ICD-9 training webinar on September 3, 2014, which ran approximately 90 minutes. Because there were only 1,000 phone lines and AdobeConnect ports, many HHAs were not able to log on to the training. CMS did tape the presentation, and will be archiving it on one of their web pages shortly. Once available, the location of the archived broadcast will be posted to the WI OASIS website, so check back here for updated information: (continued)

7 DQA Quarterly Information Update OCTOBER 2014 Page 7 Handouts used in the webinar, as well as the draft C1/ICD-9 dataset and a draft Chapter 3 of the OASIS- C1/ICD-9 Guidance Manual, can be found under Key Resources on the webpage at In addition, CMS also updated the OASIS Q&A categories 1-4 to include all C1-appropriate guidance; these categories are posted under OASIS Questions and Answers on this same webpage. CMS has since announced that ICD-10 will become effective on October 1, On that date, the OASIS- C1/ICD-9 dataset will be replaced by the OASIS-C1/ICD-10 dataset. More information from CMS will be forthcoming. This stair-stepped approach will undoubtedly help many HHAs adjust a bit easier to each change. Next DQA OASIS Educational Forum: OASIS-C1/ICD-9 Training Webinar DQA sponsors an educational venue to help Wisconsin HHAs keep current with evolving OASIS information. Entitled, The OASIS Educational Forum, Wisconsin s OASIS Education and Automation Coordinators conduct these educational offerings on a quarterly basis. Originally announced for October, the next OASIS Educational Forum will be a live OASIS-C1/ICD-9 training webinar on Thursday, December 11 th at 12:30-2:00 pm. This broadcast will be dedicated to stafflevel use of the C1/ICD-9 dataset items, with attention to changes in the C-to-C1 dataset. Additional details and webinar materials will be posted to the WI. OASIS website in the future, so please check back here for updated information: Each OASIS Educational Forum utilizes an internet meeting format for sharing information. If you are new to this format and need details about participating (such as computer requirements, testing your computer s connectivity, and a Quick Start Guide ), read the original article in the January 2013 issue of the DQA Quarterly Information Update (page 4) at: Update pdf On the day of the broadcast, connect online to our virtual meeting room at least 10 minutes prior to the start at Enter the meeting room as a Guest, then sign in with the name of your HHA and number of attendees participating from your location. To submit a suggestion for inclusion in the OASIS-C1/ICD-9 training, MaryJo.Sutton@dhs.wisconsin.gov REGULAR FEATURES Changes in DQA Staff Bureau of Education Services and Technology (BEST), Education Services Section Hired: Nikki Andrews - Section Chief (Central Office / Madison) Nikki Andrews has been appointed as the new Section Chief of the Education Services Section. Nikki has been with DQA since 2012 as a Quality Assurance Program Specialist in the Bureau of Assisted Living. In this role, she was successful in leading and managing multiple projects for the Bureau and developing and

8 DQA Quarterly Information Update OCTOBER 2014 Page 8 providing training for assisted living providers. Prior to coming to DQA, Nikki was a CBRF/AFH Administrator responsible for overseeing teams of supervisors, direct care, and office staff. Nikki has a Bachelor of Science Degree in Management and Theatre Arts from UW-La Crosse and is a graduate of the Second City Conservatory in Chicago, IL. Nikki began her new duties on July 28. Her office is located at 1 W. Wilson St., Room 450. Hired: David Soens, Civil Engineer - Advanced Consultant (Central Office / Madison) David Soens has been appointed as the new Civil Engineer - Advanced Consultant for the Education Services Section. David has been in state service since 1999, starting his career in the Engineering Consultant and Fire Authority role with the Department of Health and Family Services. David returns to the Education Services Section after serving for four years as the Director of the Office of Plan Review and Inspections (OPRI). David s leadership was fundamental in the creation of this new office, successfully leading a team of professionals in the development of OPRI policies and procedures. David has been successful in leading and managing multiple projects for the Division and developing and providing training for all provider types. Prior to his employment at DQA, David worked for the University of Wisconsin as a Program Director for the College of Engineering, as well as architect and engineer for multiple private agencies. David has a Masters of Architecture from UW - Milwaukee and a MS and BS in Mechanical Engineering from UW - Madison. David will be located in Room 450 at 1 W. Wilson St. and will begin his duties on October 6, DQA Numbered Memos (July, August, September) Access these memos at or via individual provider publication pages at DQA Memo No. Affected Provider(s) Adult Family Home Certified Mental Health and AODA Program Community-Based Residential Facility Facility Serving People with Developmental Disabilities Home Health Agency Hospice Hospital Nurse Aide Training Program Nursing Home Personal Care Provider Residential Care Apartment Complex Title Summary Application Process for Out of State Trained Nurse Aides The purpose of this memo is to provide information regarding the application process for an out-of-state trained nurse aide to provide employment history information for possible placement on the Wisconsin Nurse Aide Registry.

9 DQA Quarterly Information Update OCTOBER 2014 Page Adult Day Care Adult Family Homes Community-Based Residential Facility Residential Care Apartment Complex Community-Based Residential Facility Adult Day Care Adult Family Home Community-Based Residential Facility Residential Care Apartment Complex Nursing Home Adult Family Home Community-Based Residential Facility Plan of Correction Due Date The purpose of this memo is to announce the requirement for submission of Plans of Correction (POC) to the Department. Existing Building Conversions for New CBRF Licensure The purpose of this memo is to provide information regarding the conversion of an existing building or structure to a newly licensed Community Based Residential Facility (CBRF). Facility Closure/Relocation Plans In this memo the DQA Bureau of Assisted Living provides guidance to providers about the process to use for discharge planning and relocation assistance for residents/tenants in the event of a facility closure. Clarification Concerning Emergency Protective Placement This memo clarifies issues related to DQA Memo on the Supreme Court Decision Regarding Chapter 51 Residents with Dementia or Alzheimer s disease. Clarifications Surrounding Emergency Protective Placement Subsequent to the 2012 Wisconsin Supreme Court Decision stating persons with only dementia or Alzheimer s disease are more appropriately treated under the protective placement provisions in Chapter 55 than involuntary commitment under Chapter 51, DQA Memo was issued to address the impact of that decision. Since then, questions arose as emergency situations resulted in conflicts with administrative rules. CMS Survey & Certification Letters (July, August, September) Listed below are Survey and Certification (S&C) Letters distributed by The Centers for Medicare and Medicaid Services (CMS) since our last issue was published. The CMS Internet site for reviewing all S&C memos is located at Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html. (continued)

10 DQA Quarterly Information Update OCTOBER 2014 Page 10 S&C Memo No. Affected Provider(s) NH Nursing Home OPT Outpatient Therapy AO/RHC Rural Health Clinic Title Advance Guidance - Revisions to State Operations Manual (SOM), Appendix PP - Guidance to Surveyors for Long-Term Care (LTC) Facilities and Chapter 4 Rehabilitation Agencies: Fire Alarm Systems, SOM Appendix E Revision - Advance Copy Approval of The Compliance Team s (TCT s) Rural Health Clinic (RHC) Accreditation Program HHA Home Health Agency Outcome and Assessment Information Set (OASIS)-C1/International Classification of Diseases (ICD)-9 Webinar: September 3, CAH Critical Access Hospital NH Nursing Home Critical Access Hospital (CAH) Equipment Maintenance Requirements Release of Learning Tool on Building Respect for Lesbian, Gay, Bisexual, Transgender (LGBT) Older Adults NH Nursing Home Hospital/CAH/ASC Hospital Critical Access Hospital Ambulatory Surgery Center Hospital Hospital LSC Life Safety Code Completion of Minimum Data Set (MDS) 3.0 Discharge Assessments for Resident Transfers from a Medicare- and/or Medicaid-Certified Bed to a Non-Certified Bed Change in Terminology and Update of Survey and Certification (S&C) Memorandum Regarding Immediate Use Steam Sterilization (IUSS) in Surgical Settings Revised Guidance Related to New and Revised Hospital Governing Body and Medical Staff Regulations Categorical Waiver for Power Strips Use in Patient Care Areas Various